Blues' Quality Contract Raising Hackles in Massachusetts

Physicians say it's a bad way to pay for performance.

Major fads usually start on the West Coast and travel East. But when it comes to major healthcare reform, it would be best to look to Massachusetts for a vision of what might be coming to the rest of the country.

First introduced in 2009, the health plan's AQC now covers 680,000 of the plan's HMO members via risk-adjusted global payments that cover all outpatient, inpatient, and pharmacy services. It's an "alternative" payment method to fee-for-service payments.

There are payment incentives in the contract for medical groups to earn up to 10% more of their global budget in bonuses by meeting 64 pre-defined quality metrics from the Healthcare Effectiveness Data and Information Set (HEDIS) -- half inpatient measures and half outpatient measures. The health plan believes using the metrics can bend the healthcare cost curve while enhancing the quality of care.

It is even touting the AQC contract as a national cure for Medicare's budget problems, now that Medicare has vowed to move at least half of its beneficiaries out of fee-for-service payments and into alternative payment arrangements, like global capitation, by 2018. In Massachusetts itself, a 2012 state law mandated such a move to alternate payment systems and put strict controls on the rate of increase of healthcare spending.

The health plan has engaged consultants from Harvard Medical School to study the impact of the AQC on costs and quality, and they together have published two "Special Articles" in the New England Journal of Medicine (NEJM). The most recent article, in October 2014, showed that from 2009 to 2013 there was an 8% reduction in costs compared with controls from other health plans in other states, along with improved compliance with the HEDIS comparative metrics.

But despite its size, the plan also was noted to be the only insurer that exceeded the state's planned annual healthcare spending growth -- at 3.65% versus the benchmark of 3.6%, according to the most recent report of the state's Center for Health Information and Analysis. Blue Cross says that most of the cost savings attributed to the AQC have occurred only recently, admitting that costs exceeded budget projections in the earlier years of the AQC contracts.

Paul Levy, the former CEO of Boston's Beth Israel Deaconess Medical Center, expressed skepticism about the contract, which his hospital refused to sign. "We couldn't figure out how we would beat the budget because Blue Cross Blue Shield would not give us the data on our own patients," said Levy, who now writes a blog entitled "Not Running a Hospital." Levy said that others signed because they received "very sweet signing bonuses" -- in the form of front-loaded contracts which would be more palatable to providers.

Dana Safran, DSc, the plan's senior vice president for performance measurement and improvement, calls the idea that contracts were front-loaded "not accurate."

"From the time that we launched AQC (2009) through the subsequent several years, the pressure on costs -- and therefore on contracts – got increasingly intense," she wrote in an email. "There was not a front-loading or anything along those lines in 2009 -- but contracts in general, AQC and non-AQC, got increasingly stringent as a product of the times. Following implementation of coverage reform, attention to healthcare costs and cost growth became an increasingly important concern for customers, policymakers, payers, and the public."

Levy is worried that providers may be just now seeing the insurance risks that Blue Cross is shifting to them and they may not be prepared. "It's a huge transfer of risk to doctors and hospitals ... This is one of the greatest public policy scams that this insurance company has done in this state."

But Safran discounted the impact of risk on providers, saying that providers in Massachusetts are clamoring for risk via the AQC model and want it extended across all payment platforms; she added that downside financial risk is critical in "getting providers' attention."

Better Measures of Outcomes?

To date, few Massachusetts physicians have offered public criticisms of the AQC contracts. Most of those who spoke endorsed the use of outcomes data and quality metrics, but insisted that the metrics must make clinical sense and be constantly updated based on the best evidence.

One who has spoken out is Joel Rubenstein, MD, the retired chief of cardiology at Newton-Wellesley Hospital and a clinical professor of medicine at Tufts University in Boston. In an article in CommonWealth magazine, Rubenstein said he thinks using quality metrics like measuring cholesterol and HbA1c in diabetics doesn't reflect the outcomes that patients and doctors really care about -- like heart attack death rates, cancer treatment success rates, and hospital mortality statistics for specific procedures.

One of the principal consultants to Blue Cross, Michael Chernew, PhD, a health policy professor at Harvard Medical School, said in an interview that groups of patients with conditions like acute heart attacks and congestive heart failure were not specifically broken out in the Blue Cross-Harvard analyses, nor were their specific clinical outcomes followed.

Rubenstein thinks that the latest NEJM study showing the merits of the AQC does not show significant cost savings and he "objects to the disingenuous way this article presents this to the public."

"To advertise this as a quality contract is misleading ... it's not exactly transparent because their major concern is costs," he said.

But Safran believes that the 64 quality metrics, which she refers to as a "robust quality set," serve as brakes on undercare and set the AQC contract apart from poorly designed capitation contracts of the 1990s.

Dark Side of Metrics

Several Massachusetts physicians who practice under the AQC -- many of whom run residency training programs -- said in exclusive interviews with MedPage Today that there is a dark side to the health plan's quality metrics, which foster gaming the system, cause staff to "teach to the test," and need to be updated with better evidence-based practices.

"There are too many metrics, too confusing and too misaligned ... The AQC metrics have nothing to do with health and they don't reduce costs," said Stephen Martin, MD, professor of family medicine at the University of Massachusetts Medical Center in Worcester.

He worries about the ethics of "testing boys and girls for chlamydia without telling them," but being so busy meeting the metrics that we "fail to deal with kids who are depressed and troubled."

He has proposed other more clinically relevant quality metrics, including:

Medication reconciliation in home after discharge

Number of home visits provided

Screening for and addressing fall risk

Patient self-assessment of health status (delta over time)

Food insecurity

Ability to chew comfortably and effectively with dentition

Vision assessment and correction in place (patient has satisfactory glasses)

Hearing assessment and correction in place (patient has satisfactory hearing aids)

Decreasing tobacco use

Reliable access to home heating and cooling

Reliable transportation to appointments

Contraception

Effective addiction care

Effective chronic pain care

Daniel Mullin, PsyD, MPH, a clinical psychologist who is also at the University of Massachusetts in Worcester, said of the AQC metrics, "Even if many of them are consistent with current evidence, they still distort the system's resources."

As an example, Martin, along with Wayne Altman, MD, associate professor of family medicine at Tufts, said that some clinics call hypertensive patients in for blood pressure checks in mid-December to make sure the blood pressures meet the metrics, because the last blood pressure of the year is the one that counts for the quality bonus.

Altman explained: "You don't get any credit if the [systolic] blood pressure is 140 [mmHg], but you get credit if it's 139, so if somebody writes 139 instead of 140, it is clinically insignificant, but they don't want to lose the points so they do that."

He noted that if the physician had succeeded in bring the systolic pressure from 210 to 142, "they get nothing. If they brought them from 142 to 139 -- or didn't and just wrote it -- they get the credit."

Safran said in an email that she was not aware of anyone gaming the system that way. "It would be quite shocking if providers were engaged in this activity -- which would be falsification of clinical results."

Mullin called Safran's response "naive." "The sort of distortion of the data we are warning about is well documented in the criminal justice system and in education," he wrote in an email. "Why would we believe physicians are less vulnerable to this sort of falsification?"

Wasted Time

Altman worried that time was being wasted on learning to produce the metrics that the health plan wants. "We were given a whole conference on how to measure blood pressure properly so that the numbers are lower when the patient is seated properly and not talking."

Another physician who asked to remain anonymous said that some clinics banned the use of automated machines by aides near year end, preferring the use of manual cuffs to get better numbers. One doctor called on Blue Cross to release its blood pressure data -- betting it would show a spike in systolic readings at 138 and 139 mmHg.

"Blue Cross should be embarrassed that they have given us such thin gruel for metrics," said Martin. "You do not have to spend an hour in clinical epidemiology to understand how flawed these dichotomous numbers are and that every single one of them should be individualized per patient."

The idea of individualizing quality measures "is an idea that the measurement community has explored and not been able to operationalize," Safran said. "You can imagine the complexity if measures were tailored to the starting value of individual patients -- and the targets similarly tailored. In an environment where providers are increasingly frustrated by the number of measures, this would quite drastically exacerbate the problem."

Other physicians pointed out that many of the 64 metrics were out of date. For example, the metric for HbA1c has been individualized for patients based on factors such as age and comorbid diseases.

Many also noted that the plan's LDL quality metrics were out of line with the most recent national guidelines calling for the use of statins based on level of risk. All said they had not been contacted by the health plan regarding their opinions on the quality measures.

Safran said that Blue Cross is "meticulous about keeping up with changes in guidelines and the resulting changes in standards for measures. In fact ... the measures of statin monitoring and statin control have been eliminated from the AQC measure set as a result of the changed standard. When standards change and a measure sponsor, such as [the National Committee for Quality Assurance or the Centers for Medicare and Medicaid Services], changes or drops a measure -- we make the corresponding change in our measure set immediately."

Martin said that providers "only received word in a February 20th email that 'LDL will be excluded from total AQC measure rate calculation starting in February.' But this measure has already been promulgated and scaled and inserted into standing order sets. History shows that it won't really decrease for years, possibly decades."

Most doctors interviewed agreed that the AQC contract would not be a good model for national Medicare reform. "It would be a disaster for the country," said Martin. "It distracts us from taking care of people who need help."

The Massachusetts Medical Society said it had no comment on how the AQC was affecting providers in the state.

Brant S. Mittler, MD, JD, has been a cardiologist in private practice in San Antonio for the past 38 years and has an active litigation practice in healthcare law.

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